Journal Article > Commentary

This case report describes an incident of harm due to application of the wrong cleansing solution, discusses the risk of neonatal burns, and emphasizes the importance of vigilance to prevent such errors.

Journal Article > Study

This analysis of data reported to the National Patient Safety Agency found that most safety problems associated with airway devices occurred after the procedure (tracheotomy or endotracheal intubation) was performed and not during the procedure itself. The report makes recommendations for the proper use of monitoring equipment to ensure safety for intubated patients. An AHRQ WebM&M commentary discusses an adverse event associated with airway management during surgery.

Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.

Journal Article > Study

This study found that one-third of critically ill patients experienced an adverse event related to an invasive procedure. Infectious adverse events, namely ventilator-associated pneumonia, were more frequent than mechanical ones.